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Aki

Acute interstitial nephritis overlapping hypertensive nephropaty

Razionale

Arterial Hypertension and Diabetes Mellitus are the most predictive factors for CKD but only few patients will reach ESRD. Acute interstitial nephritis (AIN) is an important cause of AKI. The different causes of AIN can be categorized into 3 groups: drug-induced (especially NSAIDs and antibiotics), infection-related and immune complex-mediate. AIN is defined by its distinctive histological and functional characteristics. (rapid onset, laboratory evidence of AKI with proteinuria, sterile pyuria and hematuria).The triad of fever, skin rash and arthralgia is rarely present. Elderly patients are at particularly high  risk. The cumulative effects of polypharmacy, the widespread usage of medications in this age group and the decreased drug metabolism, result in increased rate of AIN in this population. 

Casistica e Metodi

A 69-year-old male, suffering from Diabetes Mellitus, Arterial Hypertension and Coronary Artery Disease started HD because of AKI. His history revealed intake of NSAIDs due to toothache, fever and myalgia. Renal ultrasonography showed no hydronephrosis, normal size and echogenicity but elevated renal arterial resistive index (RI=1). We detected pneumonia with bacteraemia from Staphylococcus Aureus. Immunological and microbiological investigations were negative.

Risultati

Treatment included volume repletion, antibiotics and a 3-days course of corticosteroid, with improvement in his symptoms. Histological picture showed severe interstitial inflammation, lack of evidence for other causes of AKI, and significant signs of vascular injury. These findings were consistent with  AIN overlapping chronic renal damage. The patient continued HD with return to normal value in two months.    

Conclusioni

AIN should be considered in cases of AKI if pre- and post-renal causes have been ruled out. In this case two processes could be occur: the direct pathological injury to the kidney or the indirect damage by medications to treat the initial infection (toothache and airways flogosis) and the dehydration due to fever, nausea and vomiting. This patient also showed marked findings of relevant vascular damage. 

Li Cavoli G, Passantino R*, Tortorici C, Bono L, Ferrantelli A, Giammarresi C, Zagarrigo C, Servillo F, Schillaci O, Coglitore M, Rotolo U
(Nefrologia-Dialisi, ARNAS Civico e Di Cristina, Palermo * Anatomia Patologica, ARNAS Civico e Di Cristina, Palermo)
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